Non-polarized cytokine profile of a long-term non-progressor HIV infected patient

brazjinfectdis2018;22(2):142–145

w w w . e l s e v ie r . c o m / l o c a t e / b j i d

The

Brazilian

Journal

of

INFECTIOUS

DISEASES

Brief

communication

Non-polarized

cytokine

profile

of

a

long-term

non-progressor

HIV

infected

patient

Ana

Flávia

Pina

_,

_Vanessa

_Terezinha

_Gubert

_de

_Matos

_,

_Camila

_Mareti

_Bonin

_,

Márcia

Maria

Ferrairo

Janini

Dal

Fabbro

_,

_Inês

_Aparecida

_Tozetti

a_{UniversidadeFederaldoMatoGrossodoSul,FaculdadedeMedicina,CampoGrande,MS,Brazil}

b_{UniversidadeFederaldoMatoGrossodoSul,CentrodeCiênciasBiológicasedaSaúde,CampoGrande,MS,Brazil} c_{DepartamentoMunicipaldeSaúde,CampoGrande,MS,Brazil}

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Articlehistory:

Received14August2017 Accepted24January2018 Availableonline21February2018

Keywords: Interleukins HIVseropositivity Diseaseprogression Antiretroviraltherapy

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TheHIV-1initialviralinfectionmaypresentdiverseclinicalandlaboratorycourseandleadto rapid,intermediate,orlong-termprogression.Amongthegroupofnon-progressors,theelite controllersarethosewhocontroltheinfectionmosteffectively,intheabsenceof antiretro-viraltherapy(ART).Inthispaper,theTH1,TH2andTH17cytokinesprofilesaredescribed, aswellasclinicalandlaboratoryaspectsofanHIV-infectedpatientwithundetectableviral loadwithoutantiretroviraltherapy.ProductionofIL-6,IL-10,TNF-␣,IFN-␥,andIL-17was detected;incontrastIL-4wasidentified.Host-relatedfactorscouldhelpexplainsuchalevel ofinfectioncontrol,namelythedifferentiatedmodulationofthecellularimmuneresponse andanon-polarizedcytokineresponseoftheTH1andTH2profiles.

©2018SociedadeBrasileiradeInfectologia.PublishedbyElsevierEditoraLtda.Thisisan openaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/licenses/ by-nc-nd/4.0/).

AccordingtotheWorldHealthOrganization,thenumberof peoplelivingwithHIVwasestimatedat36.7millionin2016.1

InBrazil,from1980toJune2016,842,710casesofAIDSwere reportedandthecountryhasannuallyregisteredanaverage of41,100cases,withtheCentral-Westregionaccountingfor 15.1%.2

Clinical course and laboratory parameters are distinct in each HIV-infected individual. According to the clinical progressiontodisease,patientscanbedividedintofast pro-gressors, slow progressors, and long-term non-progressors (LTNP).TheLTNPgroupcomprisesthe HIVcontrollers with viralloadslowerthan2000copies/mL,3_{whereastheelite}

con-∗ _{Correspondingauthor.}

E-mailaddress:[email protected](V.T.Matos).

trollerspresentundetectablelevelsofplasmaviralloadand lowviralreplicationinvivo,evidencingthemosteffective con-troloftheinfectionwithnoantiretroviraltherapy(ART).4

In LTNPanimmuneresponseseems tooccur with spe-cificCD4andCD8Tcellsthatcontroldiseaseprogression,in particularwithhighlyactiveHIV-specificcytotoxicT lympho-cyte(CTL).Intheseindividuals,CD4Tcellsarenotdepleted andactivelycontributetoantiviralimmunitywithinterferon gammaproductionandotherantiviralchemokines.5

Consideringthesmall numberofLTNPpatientsand the rare opportunity toobserve modulation of theHIV-specific response,thisstudysoughttoanalyzethecytokinepattern by measuring TH1, TH2, and TH17 cytokines for a better understandingofCD4andCD8Tcellsmodulation,aswellas otherimmunologicalfactorsinvolvedinviralcontrol. https://doi.org/10.1016/j.bjid.2018.01.003

1413-8670/©2018SociedadeBrasileiradeInfectologia.PublishedbyElsevierEditoraLtda.ThisisanopenaccessarticleundertheCC BY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/).

brazj infect dis.2018;22(2):142–145

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Table1–Viralload,CD4andCD8Tcellscountofalong-termnon-progressorHIVinfectedpatient.

Collectiondate Copies CD4 % CD8 % CD4/CD8

13/Jun/2017 Nondetected 1230 44.19 731 26.26 1.68

08/Nov/2016 <MinLim 1422 45.18 943 29.96 1.51

26/Apr/2016 Nondetected 1171 48.16 662 27.24 1.77

20/Oct/2015 Nondetected 1374 44.88 696 22.73 1.97

24/Mar/2015 Nondetected 1407 49.13 713 24.91 1.97

14/Oct/2014 Nondetected 1196 49.18 598 24.6 2.00

25/Mar/2014 Nondetected 1562 45.4 868 25.22 1.80

28/Jan/2014 <MinLim – – – – –

07/Feb/2012 <MinLim 1303 44.41 810 27.61 1.61

19/Jul/2011 <MinLim 1643 48.82 960 28.19 1.71

12/Jan/2011 <MinLim 1350 46.82 714 24.76 1.89

07/Jul/2010 <MinLim 1512 46.61 863 26.61 1.75

07/Oct/2009 <MinLim 1739 52.57 807 24.39 2.15

05/Nov/2008 <MinLim 1042 48 589 27 1.77

11/Jun/2008 <MinLim 1534 – 891 – 1.72

12/Dec/2007 <MinLim 1712 – 872 – 1.96

30/Nov/2005 <MinLim 1154 – 681 – 1.69

24/Jan/2005 <MinLim 1010 – 663 – 1.52

28/Jun/2004 <MinLim 1078 – 759 – 1.42

26/Jan/2004 <MinLim 1142 – 732 – 1.56

<MinLim,lowerlimitofdetectionof50copiesofHIV/mLofplasma.

The study was approved by the Ethics Committee on

ResearchoftheFederalUniversityofMatoGrossodoSulunder protocolnumber1.431.913.

A43-year-oldfemalepatientinitiatedmedicalfollow-up

inAugust 2003atthe Basic Health Unit of the

Municipal-ity of Ponta Porã, state of Mato Grosso do Sul – Brazil,

and continued until2017. Aftersigningthe Informed

Con-sent,two5-mL samplesofperipheralblood were collected

byvenipuncturewithoutanticoagulant.Afterseparatingthe

serum, the material was stored at −80◦ _{C for}

quantifica-tion of TH1 (IL-2, TNF, IFN-␥), TH2 (IL4, IL-6 and IL-10),

and TH17 (IL-17) cytokines, using the BD Cytometric Bead

Array (CBA)Human TH1/TH2/TH17 CytokineKit, according

tothemanufacturer’sinstructions,andtheBDFACSCantoII flowcytometer. For the analysisofresults, the FCAP array

software was used. Data from medical records were also

collected.

BesidesHIVinfectionwithoutARV,thepatientpresented somecomorbiditiessuchassystemicarterialhypertension, obesity,diabetesmellitustypeII,anddyslipidemia.Duringall yearsofHIVinfection,thepatientpresentednosigns

clin-icalofimmunodeficiency.Herrecurrentcomplaintswereof

gynecologicalorigin,suchasalterations inmenstrualflow, leucorrhoeaandvaginalpruritus,inadditiontocomplaints relatedtointermittentjointpain.Patientreportednosmoking historyoralcoholconsumption.Becauseofreferred eating-relatedandanxietydisorders,shewasunderthesupervision ofanutritionist.

Laboratory data confirmed HIV infection, dyslipidemia,

typeIIdiabetesmellitus,andoccasionalchangesintheurine test.Noopportunisticdiseaseswerediagnosed.FromJanuary 2004toJune2017HIVviralloadwasundetectable, andthe averageCD4countwas1360cells/mm3_{,withoutconsiderable} fluctuations(Table1).

Patient’scytokineprofilerevealed the presenceofIL-17, IL-6,TNF-␣,IFN-␥andIL-10.Nodetectableconcentrationsof

IL-4orIL-2werefound(Table2).Thequantificationofviral load, CD4 and CD8 T counts were not consistent with 13 years ofHIV-infection, asviralload remained undetectable andCD4countshadanaverageof1360cells/mm3

through-out thefollow-upperiod,withnomajorfluctuations.Thus, thispatientwasconsideredtobeanelitecontroller.3

InHIV-1infection,itisknownthatviraland/orhostfactors couldregulateinfectioncontrol.Amonghost-relatedfactors, modulationofcellularimmuneresponseofLTNPpatientsare distinctfromthatofpatientswithrapidorintermediate pro-gression.

HIV-1 spread throughthe lymphoid systemoccurs soon afterinfection,andtheeventsduringprimaryHIV-1infection (PHI)determinethesubsequentlowlevelofviralreplication.7

A significantdifference inviral loadwas observedinLTNP PHI,8 _{indicating that patients capable of controlling}

HIV-1 infection emerge from the PHI with low levels of viral replication.7

Whenanalyzedinvitro,CD4TcellsofLTNPincontactwith HIV-1presentasignificantpopulationofHIV-specificmemory cells.Inaddition,ithasbeendemonstratedthatCD4Tcells ofelitecontrollershavehighlyavidantigensurfacereceptor forviralpeptidessuchasGag.9_{TheseCD4Tlymphocytesare}

likelytohaveanindirecteffect,stimulatingamoreeffective CD8Tcellresponseininfectioncontrol.10

Anotherpossibilityisadirectantiviraleffectofthese HIV-specificcellswithsignificantlylowHIV-1replicationrateand vigorousCD4TcellproliferationinresponsetoHIV-1Gag.7

CD4Tcellswereidentifiedashavingacytotoxicphenotype, capableofpromotinglysisofautologousBcellscoatedwith thecognatepeptide.11_Appayetal.,12_{haveshownthatHIV-1}

infectionisassociatedwithanincreaseincirculatingCD4T cellscontainingperforins,eveninPHI,expressingmarkersof cytotoxicactivityinlargeamounts.

TheclassicalfunctionofCD8Tlymphocytesiscytotoxic activity ininfected target cells.So, lysis of LTCD8-infected

144

Table2–CytokineprofileinLTNP,HIV-1inacutephaseandhealthyindividuals.

Cytokines LTNPpatient(pg/mL) HIV-1acutephasemedianbaseline6_{(pg/mL) Healthyindividualsmedian}a_(pg/mL)

IL-17 21.22 3.90 5.90 IL-6 2.46 4.70 1.10 TNF-␣ 2.32 3.40 1.20 IFN-␥ 0.96 6.00 0.00 IL-10 0.84 10.30 0.00 IL-4 0.0 10.10 0.30 IL-2 0.0 2.20 0.00

Note:Staceyetal.6

a _{Unpublisheddata,withanaveragecytokinedosageoftenHIV,HBVandHCVnegativepatients(meanage36.6years).}

CD4Tcellswouldreduceviralreplicationandtheamountof viralDNA.Thecytotoxicityoftheselymphocytesrepresents themainmechanismforthecontrolofHIVinfection.Thus, amodificationinthemodulationofCD4Tcellsinthehost’s immuneresponseissuggested,whichwouldaltertheprofile ofcytokinesproducedbythepatient.13

MostHIV-infectedindividualswhoprogresstoAIDShave analteredproductionofHIV-specificmemoryCD4Tcellsand inabilitytoproduceIL-2inresponsetoHIVantigens.14_This

dysfunctionmayberesponsibleforasubsequentdeclinein thecytotoxicresponsetothevirus,allowingtheprogression toAIDStooccur.10

AccordingtoImamiet al.,15 _{whenadetailedanalysisof}

cytokineproductioninresponsetoHIVantigensandpeptides wasperformed,amixedTH1andTH2responseinpatients whocontrolledviremiathroughaspecificresponsetop24viral antigen was observed in progressors and non-progressors, as well as inimmunologically discordant progressors. The proliferationofCD4Tcells wasaccompaniedbytheinitial productionofIL-2andIFN-␥,withasubsequentproduction ofIL-4and a peakproductionofIL-10, suggestinga cross-modulation between TH1and TH2 cytokines. Such feature maybecrucialformaintainingthecellularresponsetoHIV-1 innon-progressors.15

IL-17isproducedbycells withaTH17profileand plays animportantroleinenterocytehomeostasisinthe gastroin-testinaltract(GIT).IL-17isalsoessentialagainstbacterialand fungalinfectionsatthesite.16_{AresponseofHIV-specific}

IL-17-producingCD4TlymphocyteshasbeendescribedandLTNP patientshavehigherIL-17productionwhencomparedwith progressorstoimmunodeficiency.17

TheIL-17productioninthe viralloadofprogressorand non-progressorpatientswasobservedinastudywhereHIV-1 infectedchildrenwithviralloadlowerthan50copies/mL pre-sentedsignificantlyhigherconcentrationofthesecytokines. ItwasnotpossibletodeterminewhetherthedecreaseinIL-17 productionisthecauseortheeffectofincreasedviremia.18,19 Thepatientpresentedanon-polarizedcytokineproduction profile,sincetheproductionofIL-6,IL-10(TH2),TNF-␣and IFN-␥(TH1)wasobserved.IL-2andIL-4werenotdetectable, whichcouldbeduetotheprolongedinfectiontimeof13years, assuchcytokinesarepartofthecharacteristicpatterninthe initialphaseofinfection.Inaddition,theproductionofIL-17 couldbeobservedinahigherlevel, whichcorroboratesthe hypothesisofagreaterproductionofIL-17inLTNPpatients withviremialower than50copies/mL.Itisdifficultto

clas-sify a patientsoon after HIVinfection orat the beginning ofmedicalfollowup,sothisLTNPpatient’sdatawere eval-uated afterPHI, but theinterferenceofother factors could notbeevaluated.Thecellsthatexpressperforinregardless ofCD8presencemayhavearoleincontrollingtheinfection. Thus,otherstudiesevaluatingHIV-infectedpatientsinthePHI phasearenecessarytoclarifythesemechanisms.

Funding

Student research grants were providedby the PIBIC-CNPq-UFMSandFUNDECT–CNPqPrograms.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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